(Sacramento, CA – January 9, 2017) Disability Rights California (DRC) found the California Department of Public Health (CDPH), which licenses nursing homes, does not consistently impose adequate penalties when a resident’s death is caused by staff misconduct. As a result, nursing home residents remain in harm’s way. The finding is contained in a report (http://www.disabilityrightsca.org/pubs/703101.pdf) DRC released today following an investigation into the deaths of nursing home residents.

“These cases were not isolated events,” said DRC attorney Pamila Lew. “We analyzed hundreds of cases and found that negligent care directly contributed to resident deaths. But the state issued lower level citations, which resulted in lighter penalties, sometimes seeming to significantly undervalue staff responsibility in the loss of life.” The report cited the case of Alejandro Reynolds, a 30-year-old man with paraplegia, who died after bleeding uncontrollably from a massive pressure sore.

DRC found his death was the result of negligent care by the nursing home staff, which should have resulted in the most severe Class AA citation. Instead, the state issued the second level, Class A citation. If a top citation had been issued, CDPH would have revoked or suspended the facility’s license after a second resident died from staff neglect.

During the investigations, DRC consulted with medical experts, including Mary Cadogan, professor at the University of California Los Angeles, School of Nursing. “This report sheds light on an urgent safety issue that must be corrected. All Californians are entitled to accurate information regarding the quality and safety of care in nursing homes.”

DRC recommends CDPH make the following changes:

Issue the highest level of citation, a Class AA, when staff conduct directly relates to a resident’s death and apply consistent standards for issuing citations, including those involving resident deaths.

Explain in a citation involving a resident death the reason a lower level of citation was issued, including why the evidence did not support a finding that staff misconduct was a direct proximate cause.

Increase the penalty amount for citations involving deaths in which staff misconduct played a part.

We are pleased that after reviewing the report, CDPH agreed to provide the public with more information about nursing home citations and resident deaths on its website. DRC is looking into legislation that would add a new citation classification when a death is involved.